Some doctors suggest that people should not receive more than two or four epidural steroid injections (ESIs) per year. However, others agree that people can safely receive up to six injections annually.

ESIs help relieve pain caused by conditions that cause irritation and inflammation of the spinal nerve root. Doctors usually use them to manage chronic low back and neck pain.

While ESIs cannot cure pain, they help relieve it for a certain time.

Guidelines on using ESIs do not specify how many are safe in a lifetime, but doctors usually recommend limiting the number of injections a person has per year. Using ESIs safely requires prescribing the lowest effective dose.

Read on to learn more about how many ESIs are safe.

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Doctors recommend limiting the number of epidural steroid injections (ESI) a person receives per year. However, recommendations on the exact number of injections a person may receive will depend on each situation.

Some factors that determine how many a person can receive include:

  • characteristics of the person receiving the injection
  • location in the spine where a doctor will administer the ESI
  • type of steroid used
  • side effects

While ESIs may be necessary for treating back or neck pain, they come with certain risks. While rare, they can cause immediate paralysis or death. Other side effects are minor or delayed.

Learn more about ESIs.

Doctors have yet to agree on the recommended maximum dose of ESIs. The following table lists the maximum annual doses for four of the most common ESIs investigated in studies.

ESI typeMaximum annual dose

Most healthcare professionals allow up to four ESIs per year. A small percentage permits six or more injections.

Multiple-high doses may cause too many risks for certain people, and side effects from ESIs often depend on the dose. It might be safer to use a moderate instead of high dose of ESI if it is still a high enough dose to manage pain.

ESIs are safe when administered by experienced professionals. However, as with all drugs, ESIs carry risks.

The Food and Drug Administration (FDA) has issued a warning about the rare but serious effects, including death:

However, these side effects come from anecdotal reports, not scientific studies.

Most side effects from ESIs are minor. For example, vasovagal effects, such as pale color to the skin, lightheadedness, and nausea, are common but minor side effects.

It is challenging for experts to know whether side effects come from the medication or the injection procedure. Some causes of side effects with ESI include:

  • damage to blood vessels or tissues due to the procedure
  • injection into the blood vessel rather than the epidural space
  • local reaction, including a bacterial infection from the procedure

Damaging blood vessels and spinal tissue is a possibility with any injection into the spine. However, an injection performed by a licensed and experienced doctor lowers a person’s risk of damage. Certain individuals, such as those taking blood thinners, are at a higher risk.

Some people may also experience delayed or long-term side effects from ESIs. These may include:

  • neurological issues
  • infections
  • increased pain
  • complications from diabetes
  • bone demineralization
  • suppressing the hypothalamic-pituitary-adrenal (HPA) axis

Before receiving an ESI, people must sign a written consent due to possible safety concerns.

Doctors administer ESI in a specific part of the spine. Specifically, they will administer the injection into the epidural space, the part of the spine filled with small blood vessels and fat.

People with pain that spreads from their back to their buttocks or their neck down their arm should contact a doctor.

If a person has had an ESI to treat pain, they should inform their doctor whether or not it is working properly. Their healthcare professional may use pain scales to communicate and measure a person’s pain. They can use this to assess medication dose and efficacy.

If pain persists or worsens after an ESI, a person should contact a doctor immediately. They should also inform a healthcare professional about any side effects they experience after having an ESI.

Experts have yet to determine how many ESIs are safe in a person’s lifetime. While most recommend less than four per year, some may permit more.

Several factors that help doctors decide include the characteristics of the person receiving the ESI, medical history, the reason for the ESI, and their experience with steroids and opioids.